Lifestyle health coaching programs have been used extensively in the U.S. and other countries for more than 15 years to provide health improvement services to employees in the workplace. These programs have become increasingly popular in Canada in the past few years with more progressive employers and have also been successfully implemented in other settings, such as hospitals, cardiac rehabilitation centres and physician practices.
Lifestyle health coaches deliver individualized lifestyle management interventions on a variety of topics: nutrition, physical activity and exercise, weight management, stress/depression management, tobacco cessation, sleep and fatigue management, preventive exams and immunizations, and reduction of cardiovascular risk factors. Ideally, lifestyle health coaching programs are integrated with—and supplement the care provided by—employees’ healthcare providers.
These programs offer health management benefits, and they can also be cost-effective. Coaching delivered from call centres via the telephone and internet by non-physicians (e.g., nurses, nutritionists, registered dietitians, exercise physiologists and health educators) has been proven to be as effective as face-to-face coaching but at a substantially lower cost, since it allows for greater scheduling flexibility, decreased travel time and lower transportation costs, according to a November 2011 article in the New England Journal of Medicine.
Health coaching is intended to help people make and adhere to meaningful lifestyle changes through the development of a supportive relationship that can help to facilitate behaviour change and attain goals. Most people who have achieved a major goal can identify one or more persons (perhaps a parent, friend, teacher or work colleague) who provided an important source of support. When it comes to making difficult lifestyle changes, such as losing weight and keeping it off, most people need specific types of social support. Health coaches are uniquely prepared to fill two important supportive roles related to behaviour change.
1. Technical assistance
This support can be provided only by someone with knowledge and insight into a specific topic or problem (e.g., an addictions counsellor). The employee can trust that the information the health coach provides is reliable and valid.
2. Technical challenge
This support holds employees accountable for their actions and progress. The coach might ask tough questions, such as “What prevented you from making progress last week?” or “What are you willing to do to show your commitment to achieving this goal?” Employees in health coaching programs say that being accountable for their actions helps develop self-responsibility and self-efficacy.
Coaching is conducted using behavioural interventions derived from well-established behaviour change models and strategies. Popular models include the stages of change model, adult learning theory, single concept learning and social learning theory.
The stages of change model suggests that individuals move through unique stages of readiness, including pre-contemplation, contemplation, preparation, action and maintenance, when attempting a behaviour change. Interventions for change are more successful when the processes of change are matched to the individual’s stage of readiness. Adult learning theory suggests that adults learn best when the educational content is immediately relevant to their daily lives. Single concept learning introduces one major skill or topic at a time in a step-by-step fashion, requiring mastery of each skill before moving forward to a new topic or skill. Social learning theory acknowledges the importance of social support in making and maintaining behaviour changes.
Health coaches guide employees through the creation of a wellness vision: a vision of the lifestyle and health status that is possible in the future. Coaches and employees then work together to develop an individualized action plan toward achieving that vision. From session to session, coaches hold employees accountable for their progress and celebrate their successes.
If the coach recognizes that a behaviour or risk is outside of the scope of the lifestyle management program, the coach will make an appropriate referral or transfer. Coaches do not psychoanalyze, diagnose or treat diseases, or prescribe medications. Resources for transfers and referrals could include the participant’s personal healthcare provider, or a disease management or employee assistance program offered through the employer.
The coaching emphasizes cognitive and behavioural processes depending on the employee’s stage of readiness for change. Cognitive processes include increasing knowledge, comprehending the benefits of behaviour change, warning of the risks and consequences of not changing, and empowering the participant to take action based on internal motivation. Participants engage in numerous self-assessment and self-monitoring activities, such as weighing the pros and cons of changing, keeping online exercise and food diaries, completing stress and smoking logs, and assessing confidence related to goal attainment and maintenance. Behavioural processes include counter-conditioning (substituting a positive behaviour for a negative one, such as taking a walk when feeling stressed instead of eating), enlisting social support, using rewards, controlling stimuli and building confidence.
Health coaches are trained to use general motivational interview techniques such as asking open-ended questions, expressing empathy, listening and reflecting, affirming and summarizing. Techniques such as dealing with resistance, recognizing the difference between the individual’s current state and the wellness vision for the future, and eliciting change talk are helpful with participants in the early stages of readiness to overcome their ambivalence or resistance to change. Participants in the action and maintenance stages respond to techniques such as goal setting, planning, committing to change and preventing slips.
Convenient, efficient and affordable services
Telephone appointments provide the maximum convenience and accessibility for participants. By using motivational interview techniques, coaches can maximize an employee’s engagement during brief yet focused sessions.
Programs that work for employees and for employers
Published studies, including randomized clinical trials and independent third-party conducted research, have documented the clinical effectiveness of lifestyle health coaching in reducing risk factors in healthy persons as well as those with certain common chronic diseases. One such study (published in Population Health Management 2010) determined how risk levels changed in participants who completed approximately 12 weeks of lifestyle health coaching. Results showed a strong population movement from higher to lower health risk stratification levels (higher to medium to lower risk) with minimal reverse flow.
Achieving high participation and engagement
Visible and consistent support from top- and mid-level management is essential to implementing successful health improvement initiatives in the workplace. According to Forrester Research, more than 70% of large-market employers in the U.S. offer tangible incentives, such as cash, gift cards, incremental flex benefit credit dollars, gym memberships or reductions in insurance premiums, to encourage employees to enrol in and complete coaching programs, and this practice is growing in Canada. In the future, incentives will be increasingly tied to outcomes-based milestones, such as improvements in biometric/clinical values. Targeted and customized communications are also helpful in encouraging participation and engagement.
Overcoming ambivalence to change
While the use of incentives may entice employees to enrol in the coaching program, many remain ambivalent to making lifestyle changes. Coaches must spend significant time helping employees to overcome their ambivalence before moving forward to develop plans for change.
Employers want to see evidence that coaching programs are cost-effective and clinically effective. Although additional research is needed in Canada, many studies in the U.S. and elsewhere document impressive reductions in both direct and indirect health expenditures. According to a February 2010 article in Health Affairs, a meta-analysis of 22 studies conducted by Harvard University researchers on costs and savings associated with workplace wellness programs in general found that medical costs fall by about $3.27 for every dollar spent on wellness programs and absenteeism costs fall by about $2.73. In a Canadian study completed by INTERxVENT, Gamma-Dynacare Medical Laboratories had an ROI on presenteeism of $4.42 for every dollar spent, plus a 35.7% improvement in medication compliance.
Health and wellness professionals, benefits consultants and HR consultants looking to implement a comprehensive wellness and disease management program should evaluate the potential provider’s program for all of these key attributes, and ensure that the program has been proven effective in published studies and is in concordance with guideline-driven recommendations.